Provider Demographics
NPI:1447426465
Name:PEARL HEALTH CLINIC
Entity Type:Organization
Organization Name:PEARL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AND CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:NAIFEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-346-7500
Mailing Address - Street 1:2705 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6601
Mailing Address - Country:US
Mailing Address - Phone:208-346-7500
Mailing Address - Fax:208-346-7501
Practice Address - Street 1:2705 E 17TH ST
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6601
Practice Address - Country:US
Practice Address - Phone:208-346-7500
Practice Address - Fax:208-346-7501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1447426465Medicaid